个人 Injury and Medical 支付形式
State Farm® provides 个人 Injury Protection (PIP) and/or Medical Payments Coverage (MPC) forms for your information. Talk to your claim associate about forms that may be needed for your claim.
康涅狄格, 缅因州, 新汉普郡, 罗德岛州, and Vermont Medical Payments Coverage (MPC) Policyholders and Injured Parties
New Jersey 个人 Injury Protection (PIP)
Forms to be Completed, Printed, Signed and Returned by the Injured Party
Policyholders, Injured Parties and Medical Providers
Claim Information Sheet — Basic Policy
Claim Information Sheet — Standard Policy
Attending Provider Treatment Plan
New Jersey PIP Pre-Service Approval Form
New Jersey PIP Post-Service Appeal Form
索赔 with Date of Loss Prior to 11/1/2011
Medical Provider Package/Conditional Assignment of Benefits
索赔 with Date of Loss On and After 11/1/2011
Medical Provider Package/Conditional Assignment of Benefits
索赔 with Date of Loss On and After 12/15/2013
Medical Provider Package/Conditional Assignment of Benefits
索赔 with Date of Loss On and After 12/1/2017
Medical Provider Package/Conditional Assignment of Benefits
索赔 with Date of Loss On and After 9/1/2023
Medical Provider Package/Conditional Assignment of Benefits
皮普供应商
New York 个人 Injury Protection (PIP)
Policyholders and Injured Parties
NF-AOB Assignment of Benefits Form
NF-2 Application for Motor 车辆 No-Fault Benefits
NF-3 Verification of Treatment by Attending Physician or Other Provider of 健康 Service
NF-4 Verification of Hospital Treatment
NF-7 Verification of Self-Employment Income
NF-8 Agreement to Pursue Social 安全 残疾人福利
NF-9 Agreement to Pursue 工人的补偿 or N.Y.S. 残疾人福利
NF-11 Additional PIP Subrogation Agreement
NF-12 Lump-Sum Settlement Agreement
NF-13 Election of Option – Optional Basic Economic Loss Coverage